A nurse is caring for a client who is 36 hours postpartum.
The nurse’s notes indicate the following: Breasts are soft, warm, and tender to touch. The client denies any nipple or breast discomfort.
The fundus is boggy, located 1 cm above the umbilicus and deviated to the right. The fundus becomes firm with massage.
The client reports abdominal cramping and rates the pain as 8 on a scale of 0 to 10. The perineal pad shows a moderate amount of lochia rubra.
The client has been given an analgesic.
After reviewing the information in the client’s medical record, which of the following complications poses the greatest risk for the client?
Postpartum hemorrhage
Infection
Thrombophlebitis
Pulmonary embolism
The Correct Answer is A
Choice A rationale
Postpartum hemorrhage is a serious condition characterized by heavy bleeding after childbirth. In the scenario described, the nurse’s notes indicate that the client’s fundus is boggy and located 1 cm above the umbilicus, which becomes firm with massage. This could be a sign of uterine atony, a leading cause of postpartum hemorrhage. Additionally, the client reports abdominal cramping and rates the pain as 8 on a scale of 0 to 10, and the perineal pad shows a moderate amount of lochia rubra. These are all signs that could indicate a postpartum hemorrhage.
Choice B rationale
While infection is a possible postpartum complication, the symptoms provided do not strongly indicate an infection. Symptoms of a postpartum infection typically include soreness, tenderness, or swelling of the belly or abdomen, chills, pain while urinating or during sex, abnormal vaginal discharge that has a bad smell or blood in it, and a general feeling of discomfort or unwellness.
Choice C rationale
Thrombophlebitis is a condition where an inflammation in a vein is caused by a blood clot, affecting normal blood flow. It commonly occurs in the legs but can occur elsewhere in the body. The symptoms include swelling of the affected area, redness of the affected area, tenderness of the affected area, warmth around the affected area, and pain. However, the symptoms provided do not strongly indicate thrombophlebitis.
Choice D rationale
Pulmonary embolism is a serious condition that occurs when a blood clot gets lodged in an artery in the lung, blocking blood flow to part of the lung. Symptoms can include shortness of breath or chest pain. However, the symptoms provided do not strongly indicate a pulmonary embolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C. . . However, it is not the first action a nurse should take when late decelerations in the FHR are noted.
Choice B rationale
Applying a fetal scalp electrode is a procedure used for continuous fetal heart monitoring during labor. It provides a more accurate and consistent transmission of the fetal heart rate than external methods. However, it is not the first action a nurse should take when late decelerations in the FHR are noted.
Choice C rationale
Changing the client’s position can help improve uteroplacental blood flow and fetal oxygenation. It is often the first action taken when late decelerations are noted in the FHR.
Choice D rationale
Increasing the rate of the IV infusion can help increase maternal blood volume and improve uteroplacental blood flow. However, it is not the first action a nurse should take when late decelerations in the FHR are noted.
Correct Answer is C
Explanation
Choice A rationale
While providing age-appropriate stimulation is important for all newborns, it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.
Choice B rationale
Educating the parents about the defect is an important part of care, but it is not the priority nursing goal. The immediate physical needs of the newborn take precedence.
Choice C rationale
This is the correct answer. The sac covering the exposed neural tissue must be carefully protected to prevent infection and further damage. Therefore, maintaining the integrity of the sac is the priority nursing goal.
Choice D rationale
Promoting maternal-infant bonding is important, but it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.
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